Final Report > Chapter 22: The Culture of the NHS > Some important features of culture

Some important features of culture

12 Organisationally, a sense of collective solidarity among the various groups of professionals in the face of what is seen as considerable adversity has been a cultural strength which has served the NHS well. We heard references to this type of `Dunkirk spirit' during the evidence in Phase One and Phase Two. The General Medical Council (GMC) referred to `a national "make do and mend" culture' [4] in the NHS: adverse circumstances seem to tap a particular quality in the national psyche. Objectively, of course, such an approach is ultimately hopeless. It exploits the preparedness of the professionals to sacrifice themselves, while exhausting them. As a recipe for the future, it is useless. What needs to be cultivated is a new sense of collective effort based on opportunity, rather than frustration.

13 A further cultural strength has been the capacity of the NHS to absorb change at a pace which would defeat many other organisations. The political nature of healthcare has meant that legislation, circulars, guidelines, targets and demands for data have rained down on those who work in the NHS. Amazingly, the NHS has kept going. But again, this has been at a significant cost to the energy and morale of those who work in it, and thus to the quality of healthcare.

14 In the face of the pace of change, and while treating ever more patients with constant pressure on resources, healthcare professionals have continued to fight for their patients' interests as they see them. This is a further strength of the culture of the NHS: the commitment of healthcare professionals to doing the best for their patients. This must not be overlooked, far less undermined, in any changes that take place.

15 Whatever the strengths, it is clear to us that there are certain negative features which also characterise the present culture of the NHS. To change a culture takes time; it takes a sense of direction and it takes determination. There are no short cuts. Patience is required. And, during this process of change, understanding by all of all is essential. If a way forward is to be charted, the first stage must be an open and honest appraisal of the culture in which healthcare is practised and an acceptance that it must develop. This process is not free from pain, particularly when those who work in the NHS already feel bruised and hurt. But it is a process which must be negotiated, for change depends on a recognition of the need to change.

16 Part of this process of understanding involves acknowledging an apparent contradiction. It is that professionals as individuals or as a group within the NHS can, as we saw in Bristol, be enormously dedicated and caring, yet, at the same time, form part of, or represent, elements that need to change. We cannot state this point too emphatically: healthcare professionals are virtually universally dedicated as individuals. But, as members of separate professions and of a large organisation, the NHS, they may not always act in the interests of patients as a whole. Their particular culture may even work against these wider interests. This is not because the professionals involved, be they managers, doctors, nurses or others, are bad people. It is merely that they have come to view the world in a particular way and, as a consequence, are unable to see the wider interests of patients as a whole (rather than the patient before them) and the wider picture of the NHS.

17 One prominent feature of NHS culture, which still persists in parts of the NHS, lies in what one contributor to our Seminars referred to as the `... built-in traditional attitudes of some healthcare professionals ...'. [5] Such attitudes discourage patients from asking questions, and lead to their being given only limited access to information, thereby preventing patients from participating fully in their care. In relation to medicine, Sir Donald Irvine has spoken of what he calls `The cultural flaws in the medical profession [which] show up as excessive paternalism, lack of respect for patients and their right to make decisions about their care ...'. [6] We heard in our Seminars that these flaws are evident in all parts of the NHS. They are not confined to one professional group but may be found at every level of the patient's encounter with the service. Yet it hardly needs to be said that such attitudes are redolent of a time now past, where those with professional expertise were automatically deferred to as `knowing best'. Today, patients increasingly want to have more information about, and to be involved in, their care. This does not mean that they do not respect or value professional expertise. Rather, it means that such expertise has to be used in a different, sharing and more open way.

18 This old-style paternalism is evident in the adherence to the idea of hierarchy. As was revealed in the course of the Seminars and by the evidence in Phase One, the continued existence of a hierarchical approach within and between the healthcare professions is a significant cultural weakness. While the situation has changed somewhat over the past decade or so, the problem remains. Even today, in some places, it is assumed that a doctor's view is inevitably superior and that nurses are there to carry out a doctor's orders. This continues despite the very great efforts made by the nursing profession to create a relationship of mutual dependence and respect between doctors and nurses. [7] Many nurses in hospitals and elsewhere still do not feel valued by their medical colleagues or by managers. A sense of hierarchy also persists within medicine. The role of a hospital consultant, for example, is regarded as of higher status than the role of a general practitioner. Indeed, Sir Donald Irvine, himself a GP and President of the GMC, has spoken of how, at the start of the NHS, general practice had a very low status with no impact on the culture of medicine. [8] Much has changed since then, but the resonance of these assumptions about ranks within medicine persist. More persistent still, perhaps, is the sense of hierarchy between different medical specialties within hospital medicine, such that, for example, as the evidence in Phase One indicated, if a surgeon is in the room, it is he, at least in his eyes, who is `in charge'. Of course, if he is the person with the most appropriate skills to be in charge this is not a problem. It becomes a problem if status or title can be used automatically to supersede the authority of another more qualified to be in charge. Clearly, these aspects of the current culture of the NHS are simply inappropriate. They are a product of dated professional self-images which are already on the wane. Where they persist, they affect behaviour; they are a powerful force militating against teamwork, particularly among younger staff, anxious not to fall foul of those with power or authority.

19 Subservience or deference to a perceived superior can be a particular barrier when issues arise among healthcare professionals about a colleague's performance. [9] Although there is now a duty on doctors and nurses to protect patients from risk and not to suppress concerns about a colleague's performance, very many in practice today were educated and trained in a culture in which there was a reluctance to criticise or comment upon the conduct of colleagues, particularly those who were more senior or practised in the same team or specialty. This is the negative side of the tradition of group loyalty which has been a strength in times of relative adversity. It continues to be a negative aspect of NHS culture. Not only does it make it difficult for an individual to summon up the courage not to conform, but this sense of hierarchy also influences who gets listened to within the organisation when questions are raised.

20 A further cultural problem arises from the strong claim made by some doctors to `clinical freedom.' The weakness is as much symbolic as actual, signifying as it does some claim to an autonomy which sits uncomfortably in a large, complex organisation seeking to adhere to agreed standards within limited resources. In essence, an appeal to `clinical freedom' is a claim that in the care of a patient, the doctor's decision is the determining decision and may not be challenged. On one level, of course, this approach reassures patients that the doctor is `in their corner' and puts their interests first. But, there is an all-too-real danger that the doctrine becomes merely code for `doctor knows best' and will brook no argument. In a modern, managed healthcare system, where healthcare professionals must work in teams, such an approach may be counterproductive. It does not serve the interests of the patient. Equally, against a background of constrained resources, it may not always be right for the individual doctor treating a particular patient to insist on having his or her way, if the price to be paid is to limit or impair the care available for other patients. It was for this reason that Sir Alan Langlands described clinical freedom as `... romantic notions ... in a bygone age', and `... not a phrase I have heard for a very long time in the National Health Service'. [10]

21 Also problematic is the friction between clinicians on the one hand and managers on the other, akin, in places, to a type of guerrilla warfare. We have made it clear that, for us, all are healthcare professionals. They are all involved in different ways in serving patients and the public. The frustrations and difficulties of the past two decades, not least the changes in 1991, and the different perspectives of these two groups of professionals, have led to a degree of struggle and conflict, as unnecessary as it is unhelpful. This is not a struggle where one side is ever going to triumph over another: nor should it be. But, while it has existed, it undoubtedly has affected the quality of the care which patients have received. We have little doubt that once there is a real understanding of the various roles and responsibilities each must play in the NHS, this cultural barrier to change will begin to disappear. There will be a recognition that just as nurses and doctors work hard and that we need them to be highly skilled and caring, so the same is true of managers. They are hard-working, theirs is real work, and we need them to be good at their job. As the NHS Confederation put it in one of their papers for Phase Two:

`A relationship that in the past has suffered from much mutual mistrust must be rebuilt on a foundation of mutual respect. Managers and doctors each have very high levels of expertise that will serve the NHS far better if they are understood by all to be separate but equally beneficial. Tribalism must be eliminated and replaced by far better mutual understanding.' [11]

22 As with everything, there is a history to what the NHS Confederation calls `mistrust'. In the period after the creation of the NHS, clinicians looked after all aspects of clinical care and `administrators' were there to support. There was, as we have seen, a `deeply rooted reserve' about becoming involved in clinical matters which went right to the top of government. The change in the 1980s and 1990s was dramatic. Managers were expected to manage, and that included all aspects of the NHS. They were understandably perceived by some clinicians, however, as being the people who limited or rationed the care which they were trying to deliver to their patients, or who asked for ever greater `efficiencies'. This history must be put behind us. The quality of clinical care is self-evidently the responsibility of all who work in a trust (and is now explicitly so according to the principles of clinical governance). As the NHS Confederation put it:

`Doctors see themselves as accountable to their patients, their Royal Colleges, the GMC and their consciences. ... From the Manager's point of view there is a higher imperative; to balance the twin pressures of limited supply of resources ... with the ever increasing local demand for more and better healthcare. Both views are legitimate.' [12]

We would interject that the manager's imperative is not necessarily `higher': it is merely different and that is the point. Sir Donald Irvine expressed well the need to move forward in his Lloyd Roberts Lecture when he said:

`... it [the medical profession] needs to develop better communication with and respect for managers, to understand the pressures and constraints upon them. Doctors and managers together have to make the system work for patients. Only by working together and helping each other can they start to do so.' [13]

Footnotes

[4] Seminar 3. General Medical Council. Position Paper

[5] Seminar 3. Association of Community Health Councils for England and Wales. Position Paper

[6] Sir Donald Irvine. `The changing relationship between the public and medical profession'. Lloyd Roberts Memorial Lecture. Royal Society of Medicine, 16 January 2001. www.gmc-uk.org

[7] Seminar 3. The Royal College of Nursing. Position Paper

[8] Sir Donald Irvine. `The changing relationship between the public and medical profession'. Lloyd Roberts Memorial Lecture. Royal Society of Medicine, 16 January 2001. www.gmc-uk.org

[9] Some would see Dr Bolsin as having been in that position. See chapters on Concerns in Section One

[10] T65 p.5 and T65 p.106 Sir Alan Langlands

[11] Seminar 3. NHS Confederation. Position Paper

[12] Seminar 3. NHS Confederation. Position Paper

[13] Sir Donald Irvine. `The changing relationship between the public and medical profession'. Lloyd Roberts Memorial Lecture. Royal Society of Medicine, 16 January 2001. www.gmc-uk.org